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Emergency Department Coding and Documentation – Existing Guidelines and Changes in 2018

by | Jan 4, 2018 | Medical Coding News, Resources | 0 comments

Emergency medicine has changed rapidly and significantly over the years. Today, the emergency departments (EDs) are diagnosis and treatment hubs for emergency as well as non-critical patients. As the American College of Emergency Physicians (ACEP) notes, much of the evaluation and investigation which was previously performed as an inpatient is now being done routinely in EDs. The increase in the intensity of ED services have amplified the complexity of coding for the various types of emergency department visits. In addition to being well-versed in reporting existing ED codes, physicians and medical coding companies need to prepare for coding changes effective January 1, 2018.

  • ED Evaluation & Management (E/M) Codes (99281-99285)
    This code set comprises five different levels of service based on the nature of the presenting complaint to reveal the amount of history obtained, exam performed, diagnostic testing required and complexity of medical decision making.

    • 99281 Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: a problem focused history; a problem focused examination; and straightforward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are self limited or minor.
    • 99282 Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: an expanded problem focused history; an expanded problem focused examination; and medical decision making of low complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of low to moderate severity.
    • 99283 Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: an expanded problem focused history; an expanded problem focused examination; and medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate severity.
    • 99284 Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: a detailed history; a detailed examination; and medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of high severity, and require urgent evaluation by the physician but do not pose an immediate significant threat to life or physiologic function.
    • 99285 Emergency department visit 99285 is used for the evaluation and management of a patient, which requires these 3 key components: a comprehensive history; a comprehensive examination; and medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of high severity and pose an immediate significant threat to life or physiologic function.

    Points to note:

    • In view of the multi-tasking performed by emergency physicians, the ED code set does not have typical times assigned.
    • Medicare requires that modifier-25 always be appended to the ED E/M code (99281-99285) when provided on the same date as a diagnostic medical/surgical and/or therapeutic medical/surgical procedure(s).
  • Observation Codes (99217-36) An initial Observation Care CPT code (99218-99220) can be reported only by the physician supervising the care of the patient designated as “observation status”. Per CPT, these codes apply to all evaluation and management services that a practitioner provides on the same date of initiating “observation status”.
    • 99217 Observation care discharge day management “includes final examination of the patient, discussion of the hospital stay, instructions for continuing care and preparation of discharge records.”
    • 99218 Initial observation care, per day, for problems of low severity. Documentation requires a detailed or comprehensive history, a detailed or comprehensive exam, and straightforward or low complexity MDM.
      Typically 30 minutes are spent at the bedside and on the patient’s hospital floor or unit.
    • 99219 Initial observation care, per day, for problems of moderate severity. Documentation requires a comprehensive history, a comprehensive exam, and moderate complexity MDM. Typically, 50 minutes are spent at the bedside and on the patient’s hospital floor or unit.
    • 99220 Initial observation care, per day, for problems of high severity. Documentation requires a comprehensive history, a comprehensive exam, and high complexity MDM. Typically 70 minutes are spent at the bedside and on the patient’s hospital floor or unit.
    • 99224-99226 A subsequent observation care CPT code should be used by the supervising physician when a patient is held in observation status for more than two calendar dates.
    • 99234-99236 Observation or Inpatient Care Service (Including Admission and Discharge Services) is to be used by physicians who admit a patient to Observation Care for a minimum of 8 hours, but less than 24 hours and subsequently discharge on the same calendar date.

    Points to note:

    • Observation is defined by the service provided, not the area of the hospital a patient is located in, that is, the patient does not have to be admitted to an observation unit in order for the emergency room physician to provide observation care.
    • Emergency physicians can use observation codes whenever there is diagnostic uncertainty requiring extended evaluations, treatments and serial examinations to determine whether a patient requires admission or can be safely discharged home.
    • These codes are used for Medicare patients who spend <8 hours in observation status.
    • Observation care codes are not separately reimbursable services when performed within the assigned global period as these codes are included in the global package
  • Critical Care Codes (99291-92)
    When emergency physicians provide services to critically ill patients, the following critical care codes should be reported:

    • 99291 Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes
    • 99292 Critical care, evaluation and management of the critically ill or critically injured patient; each additional 30 minutes (List separately in addition to code for primary service)CPT defines a critical illness or injury as an illness or injury that acutely impairs one or more vital organ systems such that there is a high probability of imminent or life threatening deterioration in the patient’s condition. Critical care services are defined as a physician’s direct delivery of medical care for a critically ill or critically injured patient.

    Additionally, CMS instructs that to qualify as critical care for Medicare patients, it is necessary that “the failure to initiate these interventions on an urgent basis would likely result in sudden, clinically significant or life threatening deterioration in the patient’s condition”.

  • Other Important Codes to Report
    ER physicians should be knowledgeable about the distinct CPT codes for commonly performed procedures such as laceration repair, intubation, central lines, lumbar punctures, and paracentesis as well as orthopedic procedures like fractures and dislocations. All procedures performed should be properly reported in addition to any separately identifiable evaluation and management service provided.
    In addition, emergency physicians review and interpret EKG, Radiology and Ultrasound procedures and can bill these services if certain criteria are met. All reviews and interpretations should be documented to accurately reflect the complexity of medical decision making.
  • CPT Code Changes for Emergency Medicine in 2017
    In 2017, the most significant change was the introduction of a new series of moderate (conscious) sedation codes by the American Medical Association (AMA).
    Moderate (Conscious) Sedation [MCS], is a drug induced depression of consciousness. The patient maintains the ability to respond purposely to verbal direction or verbal direction either alone or accompanied by light tactile stimulation. Interventions are not required to maintain the patient’s airway.
    New codes (99151–99157) replaced deleted moderate (conscious) sedation codes (99143–99150). These codes are time and age based. The updated intra-service time thresholds have dropped from 30 minutes to 15 minutes.
  • ED Coding Alert 2018
    Starting Jan 1, 2018, TCI SuperCoder alerts emergency room medical billing service providers to prepare for the following changes:

    • Four new chest x-ray codes: Existing chest x-ray codes 71010-71035 will be deleted effective Jan 1, 2018 and replaced by the following new codes:
      • 71045 (Radiologic examination, chest; single view)
      • 71046 (Radiologic examination, chest; 2 views)
      • 71047 (Radiologic examination, chest; 3 views)
      • 71048 (Radiologic examination, chest; 4 or more views)
    • Three new abdominal x-ray codes: Effective Jan 1, the following abdominal x-ray codes will replace the previous abdominal x-ray codes 74000-74022:
      • 74018 (Radiologic examination, abdomen; 1 view)
      • 74019 (Radiologic examination, abdomen; 2 views)
      • 74021 (Radiologic examination, abdomen; 3 or more views)
    • Expansion of ultrasound of extremities descriptors: The introduction to the extremities codes in the CPT ultrasound section has been expanded significantly.
      Example: CPT notes now include a new descriptor for Ultrasound: complete joint (i.e., joint space and peri-articular soft-tissue structures), real-time with image documentation) “requires ultrasound examination of all of the following joint elements: Joint space (e.g., effusion), peri-articular soft tissue structures that surround the joint (i.e., muscles, tendons, other soft-tissue structures), and any identifiable abnormality.

      To report this code as of Jan 1, CPT indicates that ED physicians must also permanently record the images and maintain a written report with a description of each element visualized “or reason that an element(s) could not be visualized (e.g., absent secondary to surgery or trauma).

    • New laboratory codes: ER physicians can order a multitude of blood tests for their patients. They will need to report new microbiology codes for RSV and Zika virus starting Jan 1, 2018:
      • 87634 (Infectious agent detection by nucleic acid [DNA or RNA]; respiratory syncytial virus, amplified probe technique)
      • 87662 (Infectious agent detection by nucleic acid [DNA or RNA]; Zika virus, amplified probe technique)

      In 2018, CPT also changes the descriptor for 36140 (Introduction of needle or intracatheter, upper or lower extremity artery). Instead of the existing reference to “extremity artery”, the new descriptor specifies that the code refers to either the upper or lower extremity artery.

    • Minor Change to “Initial Observation Care, New and Established Patient”: The words “outpatient hospital’ has been inserted before the term “observation status” in the preamble to the “Initial Observation Care, New and Established Patient’ section of CPT and the full code descriptors for 99217-99220. It now reads as follows:
      “The following codes are used to report the encounter(s) by the supervising physician or other qualified health care professional with the patient when designated as outpatient hospital ‘observation status’.”

    TCI SuperCoder notes that this change may not affect hospital-based EDs, but it could impact free standing emergency centers if they are deemed not to be outpatient hospitals.